Bypass Surgery Research Articles

Evaluation of the effects and plasma concentration of the platelet inhibitor ticagrelor, after crushed and non-crushed intake, after cardiac arrest and after semi-urgent coronary artery bypass surgery

Background Ticagrelor, used in acute coronary syndrome (ACS), can be administered via nasogastric tube when oral intake is impossible. We investigated platelet inhibition and pharmacokinetics in resuscitated ACS patients and those undergoing semi-urgent coronary artery bypass graft (CABG) surgery. Our study aimed to assess platelet inhibition with use of the Platelet Function Analyser (PFA) and measured plasma concentrations of ticagrelor and its active metabolite in these ACS patients. Methods We included resuscitated cardiac arrest patients (STEMI/NSTEMI) and semi-urgent CABG patients. Crushed ticagrelor tablets were administered using a nasogastric tube. PFA closure time (CT) was determined with CT longer than 113 s as reference range. Plasma concentrations of ticagrelor and its active metabolite were measured after protein precipitation, by using liquid chromatography with mass spectrometry detection. Results In 20 resuscitated patients, 89% showed platelet inhibition at 24 h and 92% at day 4. For semi-urgent CABG patients, 85% exhibited platelet inhibition at 24 h and 84% at day 4. For ticagrelor in resuscitated patients, the median time to peak plasma concentration (Tmax) was 100 h [8; 100] for a median maximal concentration (Cmax) of 615.5 ng/mL [217.5; 1385.0]. For AR-C124910XX median Tmax was 100 h [8; 100] for a Cmax of 131.0 ng/mL [52.1; 177.7]. Among 20 patients undergoing semi-urgent CABG, Tmax for ticagrelor was 100 h [100; 100] for a median Cmax of 857.0 ng/ml [496.8; 1157.5]. For AR-C124910XX, median Tmax was 100 h [43; 100] for a Cmax of 251.0 ng/ml [173.0; 396.5]. Conclusion Crushed ticagrelor via nasogastric tube achieved targeted platelet inhibition. Pharmacokinetics aligned with previous studies. EudraCT number: 2013-004191-35; Study protocol code: AGO/2013/011; EC/2014/1061; ClinicalTrial.gov identifier: NCT02341729

National Trends and Outcomes of Pedal Bypass Surgery

ObjectiveThe technical demands associated with pedal bypass (PB) surgery place it at risk of underutilization and may be limiting its widespread adoption as a valuable revascularization modality. This study aims to evaluate trends in PB performance, assess its outcomes, and compare its results between high- and low-volume centers. MethodsAll patients receiving a PB between 2003 and 2023 were identified in the Vascular Quality Initiative (VQI) infrainguinal bypass (IIB) module. The ratio of PB to total IIB performed was calculated for each year and trended over the study period. Centers performing PB were categorized according to their annual PB volume into tertiles of low-volume centers (LVC, <2 PB/year), medium-volume centers (MVC, 2-4 PB/year), and high-volume centers (HVC, >4 PB/year) for comparison. Patient characteristics and outcomes were compared using the χ2 or Fisher exact test as appropriate for categorical variables and the analysis of variance test or Kruskal-Wallis test as appropriate for continuous variables. Cox regression analysis was used to study the association between center volume and the primary outcomes of primary patency, primary-assisted patency, secondary patency, reintervention, amputation, and major adverse limb events (MALE), defined as the composite outcome of amputation and/or reintervention. ResultsA total of 3466 patients received a PB during the study period. The ratio of PB to IIB dropped from 14% to 4% between 2003 and 2023. Primary, primary-assisted, and secondary patency rates were 65%, 76%, and 80%, respectively, and limb salvage rate was 83% at 1 year. Nineteen percent of centers performing IIBs in the VQI did not perform any PBs during the study period. Of the 246 centers performing PBs, 78% were LVC, 15% were MVC, and only 7% were HVC. On Cox regression analysis, HVCs were associated with a lower risk of primary patency loss (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66-0.95; P = .010), reintervention (HR, 0.75; 95% CI, 0.60-0.95; P = .016), amputation (HR, 0.77; 95% CI, 0.61-0.98; P = .034), and MALE (HR, 0.78; 95% CI, 0.66-0.93; P = .005) compared with LVCs. No difference in secondary patency between high- and low-volume centers was observed (P = .680). ConclusionsThe utilization of PB operations experienced a four-fold decrease over the past 20 years, despite favorable patency and limb salvage outcomes. Centers with a higher operative volume in PB achieve better outcomes than LVCs, and accordingly, patients with extensive tibioperoneal disease may benefit from evaluation at centers with documented expertise in PB before resorting to an alternative revascularization modality or a major limb amputation.

Simultaneous treatment of large hiatal hernias during Roux-en-Y gastric bypass: technical considerations and outcome.

Roux-en-Y gastric bypass (RYGB) is the preferred surgical option for patients with proven gastroesophageal reflux disease and obesity grade ≥ II (BMI ≥ 35kg/m2). Data on simultaneous treatment of larger hiatal hernias during RYGB are scarce. From 2012 until 2022, data from all consecutive patients undergoing gastric bypass procedures were collected and retrospectively analyzed. The characteristics and surgical outcomes of patients undergoing RYGB alone (RYGBa) versus RYGB with simultaneous treatment of a large hiatal hernia (RYGB-HH) were compared. Out of 573 patients who received RYGB, we identified 12 simultaneously treated for large hiatal hernia. The characteristics of RYGB-HH versus RYGBa patients were higher age (55 vs. 44years; p = 0.004) and lower BMI (39.2 vs. 46.9kg/m2; p = 0.001). Duration of surgery in the RYGB-HH group was longer (144min vs. 98min; p < 0.001), while complications > Clavien-Dindo II were similar compared to the RYGBa group (8.3 vs. 9.4%, p = 0.56). Length of stay did not differ among the groups (4 vs. 5.5days, p = 0.051). At a median follow-up of 12months, there was no clinical recurrence of hiatal hernia in the RYGB-HH group. Simultaneous treatment of large hiatal hernias during Roux-en-Y gastric bypass surgery prolongs operation time but seems feasible and safe in the hands of experienced surgeons.

Comparative analysis of the structure of the heart and blood vessels surgeries, taking into account the clinical and functional status of patients with coronary heart disease in 2015 and 2020

Relevance. In a very short period of time, surgical treatment methods have become widespread due to the expansion of indicators for performing heart surgery in patients with severe complicated forms of coronary heart disease and the use of combined surgical operations.Aim: To study changes in the clinical and functional status of patients depending on the type of surgical intervention for coronary artery disease in different time periods in the gender aspect.Material and Methods. The study was conducted retrospectively. For comparative analysis, patients with an established diagnosis of coronary heart disease who underwent surgical treatment at the Federal Center for Cardiovascular Surgery of the of the Ministry of Healthcare of the Russian Federation (Chelyabinsk) in 2015 (n = 1017) and 2020 (n = 967) were included. Of the total number of patients in 2015, there were 771 (75.8%) men and 246 (24.2%) women, in 2020 718 (74.3%) and 249(25.7%), respectively.Results. In the structure of interventions performed, there is a decrease in the number of almost all types of surgical interventions for complications of myocardial infarction, most pronounced in relation to resection of the left ventricular aneurysm, reconstruction of the left ventricle and operations in combination with mitral valve replacement. In a large percentage of cases, patients with a history of risk factors for cardiovascular diseases are referred for coronary artery bypass surgery, regardless of gender. The majority of patients had angina pectoris of the 3rd–4th functional class. However, there is a trend towards a decrease in the proportion of people with post-infarction cardiosclerosis when referred for surgery.Conclusion. Despite the significant volume and availability of practical information, the number of patients with major cardiovascular risk factors is not decreasing.

Assessment of chronical total occlusions management in France: The ENCOCHE Registry, a prospective, multicentric study

BackgroundCoronary chronic total occlusions (CTO) are frequent, and coronary angioplasty has been increasingly used in recent years for lesion revascularisation. However, to date, no dedicated multicentric prospective study is available in France. AimTo describe the characteristics of CTO patients and to assess current treatment strategies in French catheterisation laboratory practice. MethodsPatients presenting with CTOs were included from 16/09/2021 to 13/12/2021 over two consecutive prospective phases. In phase I (one month), data were collected to include all patients presenting CTO at diagnostic angiography. In phase II (two months), data were collected focusing on patients who underwent CTO-PCI. ResultsA total of 1303 patients (1460 CTOs) were included in 68 French centres. The mean age was 67.7±10.7 years and 84.3% of the patients were men. The prevalence of prior PCI (44.6%), and diabetes mellitus (35.6%) was high. In phase I, multivessel coronary artery disease was detected in two-thirds of cases, and most of them (88.5%) had a single CTO. The mean J-CTO score was 1.9±1.2, with a proportion of difficult and very difficult CTO (J CTO score ≥2) of 61.1%. The selected treatment was medical therapy in 57% of cases, coronary angioplasty in 30% and bypass surgery in 13%. In phase II, 528 patients were included with a mean J-CTO score of 1.8±1.2. Successful guidewire crossing through CTO lesion was obtained with an antegrade access in 89% of patients. Procedural success rate of CTO-PCI was 80%, with a rate of major in-hospital complications of 1% (death: 0.4%, MI: 0.2%, stroke: 0.2%, emergency CABG: 0.2%). ConclusionThis prospective study provides a snapshot of CTOs prevalence and CTO treatment strategies in France in 2021.

Expression of the Aim2 Inflammasome in Skeletal is Modulated by Surgical Bypass And is a Target to Reduce Ischemic Myopathy in Pad

Expression of the Aim2 Inflammasome in Skeletal is Modulated by Surgical Bypass And is a Target to Reduce Ischemic Myopathy in Pad

Female patients have fewer limb amputations compared to male patients in the BEST-CLI trial

ObjectiveFemale patients are less likely to be diagnosed with and treated for peripheral artery disease. When treated, there are also reported sex disparities in short- and long-term outcomes. We designed this study to compare outcomes after open and endovascular revascularization in the Best Endovascular vs best Surgical Therapy in patients with Critical Limb Ischemia (BEST-CLI) trial between females and males, and to examine outcomes of each revascularization type in an all-female cohort. MethodsIn a secondary analysis of cohorts 1 and 2 of the BEST-CLI Trial, patients with chronic limb-threatening ischemia (CLTI) undergoing open surgical bypass (with or without adequate conduit) and endovascular therapy were stratified by sex. In addition, in a female-only cohort, we evaluated differences in outcomes between treatment arm (combined all bypasses from cohorts 1 and 2 and compared with all endovascular treatment in cohorts 1 and 2). Outcomes included major amputation, reintervention, major adverse limb event (MALE, a composite of major amputation and reintervention), all-cause death, and composite outcome of MALE or all-cause death. Univariable and adjusted Cox regressions were used to assess outcome between males and females. Similar methods were used to assess differences in outcomes between treatment arm in females. ResultsAmong 1830 patients, females were significantly underrepresented, comprising only 28% (n = 519) of the BEST-CLI cohort. Overall, the characteristics of females enrolled in the trial had some differences compared with males: females were more likely to have rest pain alone (72% vs 60%; P < .0001) and when presenting with an ischemic wound, were less likely to have a wound infection (38% vs 47%; P = .01). Females were less likely to have an adequate single-segment greater saphenous vein (SSGSV) available (82% vs 89%; P = .01). Controlled for baseline clinical factors, at 1 year, females had significantly lower rates of major limb amputation compared with males (hazard ratio [HR], 0.70; P = .023), which drove better amputation- and MALE-free survival rates. All-cause death at 1 year was not statistically different between sexes (11.8% vs 11.2%; P = .286). In the all-female cohort, results paralleled the overall trial; open surgical bypass (with any conduit) had significantly better outcomes compared with endovascular therapy. Specifically, among females undergoing endovascular therapy, the rate of major reintervention was particularly high compared with females undergoing open surgical bypass (24.8% vs 10.5%; P < .001). ConclusionsDespite being underrepresented in BEST-CLI, the primary results of the trial, namely, improved MALE-free survival with open surgical bypass with SSGSV, were mirrored in the all-female subset. Female patients enrolled in BEST-CLI had better amputation-free survival at 1 year compared with male patients. These findings suggest that in treating female patients with CLTI considered appropriate for both open and endovascular revascularization, surgical bypass with optimal conduit is the preferred treatment option and can potentially ameliorate poor limb preservation outcomes associated with sex.

S191 Characteristics and Predictors of Adverse Post ERCP Outcomes in Patients With Roux-en-Y Gastric Bypass (RYGB) Surgery

S191 Characteristics and Predictors of Adverse Post ERCP Outcomes in Patients With Roux-en-Y Gastric Bypass (RYGB) Surgery

Small molecule modulation of insulin receptor-insulin like growth factor-1 receptor heterodimers in human endothelial cells

ObjectivesThe insulin receptor (IR) and insulin like growth factor-1 receptor (IGF-1R) are heterodimers consisting of two extracellular α-subunits and two transmembrane β -subunits. Insulin αβ and insulin like growth factor-1 αβ hemi-receptors can heterodimerize to form hybrids composed of one IR αβ and one IGF-1R αβ. The function of hybrids in the endothelium is unclear. We sought insight by developing a small molecule capable of reducing hybrid formation in endothelial cells. MethodsWe performed a high-throughput small molecule screening, based on a homology model of the apo hybrid structure. Endothelial cells were studied using western blotting and qPCR to determine the effects of small molecules that reduced hybrid formation. ResultsOur studies unveil a first-in-class quinoline-containing heterocyclic small molecule that reduces hybrids by >50% in human umbilical vein endothelial cells (HUVECs) with no effects on IR or IGF-1R. This small molecule reduced expression of the negative regulatory p85α subunit of phosphatidylinositol 3-kinase, increased basal phosphorylation of the downstream target Akt and enhanced insulin/insulin-like growth factor-1 and shear stress-induced serine phosphorylation of Akt. In primary saphenous vein endothelial cells (SVEC) from patients with type 2 diabetes mellitus undergoing coronary artery bypass (CABG) surgery, hybrid receptor expression was greater than in patients without type 2 diabetes mellitus. The small molecule significantly reduced hybrid expression in SVEC from patients with type 2 diabetes mellitus. ConclusionsWe identified a small molecule that decreases the formation of IR: IGF-1R hybrid receptors in human endothelial cells, without significant impact on the overall expression of IR or IGF-1R. In HUVECs, reduction of IR: IGF-1R hybrid receptors leads to an increase in insulin-induced serine phosphorylation of the critical downstream signalling kinase, Akt. The underpinning mechanism appears, at least in part to involve the attenuation of the inhibitory effect of IR: IGF-1R hybrid receptors on PI3-kinase signalling.

Efficacy and safety of endoscopic ultrasonography (EUS) hepaticogastrostomy (HGS) versus choledochoduodenostomy (CDS) in ERCP-failed malignant biliary obstruction: A systematic review and META-analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in managing malignant biliary obstruction. The success of ERCP has limitations, whereas surgical biliary bypass and percutaneous transhepatic approaches, as alternative modalities, come with significant costs, longer durations, and higher levels of mortality and morbidity. Endoscopic ultrasonography (EUS)-guided biliary drainage with two approaches, hepaticogastrostomy (EUS-HGS) and choledochoduodenostomy (EUS-CDS), is a favored and evolving alternative modality. This study aims to compare the efficacy and safety of EUS-HGS and EUS-CDS. We conducted a systematic review and meta-analysis by searching PubMed, ScienceDirect, Cochrane Library, and Scholar databases up to August 2023, based on the 2020 PRISMA guidelines. We identified randomized and nonrandomized studies comparing the efficacy and safety of EUS-HGS and EUS-CDS. Outcome measures included technical and clinical success, side effects, and mean procedure time. Nine nonrandomized studies and two randomized controlled trials involving 537 patients (225 EUS-HGS, 312 EUS-CDS) were analyzed. No difference was found in technical success (OR, 0.83; 95% CI, 0.41-1.68; I 2 = 0%) and clinical success between the two procedures (OR, 0.96; 95% CI, 0.51-1.81; I 2 = 9.94%). Side effects were significantly higher in EUS-HGS (OR, 2.01, 95% CI, 1.14-3.59; I 2 = 0%). No significant difference in mean procedure time was observed between the two procedures (0.13; 95% CI, -0.15-0.41; I 2 = 34.89%). There are differences in efficacy and safety between EUS-HGS and EUS-CDS. EUS-CDS has a faster procedure time, lower risk of side effects, and ease of puncture during the procedure.

S5154 Management Considerations in a Patient With a CDH1 Pathogenic Variant With a History of Roux-en-Y Gastric Bypass Surgery

S5154 Management Considerations in a Patient With a CDH1 Pathogenic Variant With a History of Roux-en-Y Gastric Bypass Surgery

Outcomes of Single versus Sequential Vein Grafts in Isolated Coronary Artery Bypass Surgery: Insights from a Large Tertiary Care Center

BackgroundSaphenous venous grafts (SVG) remain the most widely used conduits in coronary artery bypass graft surgery (CABG). Data comparing outcomes of single saphenous venous grafting (SinCABG) versus sequential venous grafting (SeqCABG), however, are limited. MethodsBetween 2002 and 2012, 2,375 patients with 3-vessel coronary artery disease underwent isolated elective CABG at the Leipzig Heart Center with a left internal mammary artery graft to left anterior descending artery and ≥2 distal SVG anastomoses. Of these, 1,278 received ≥2 singular saphenous venous grafts (SinCABG) and 563 received ≥1 sequential saphenous vein grafts with >1 distal anastomoses (SeqCABG). The primary end point was long term survival. Secondary outcomes included short-term survival, early postoperative outcomes as well as early and late graft patency. ResultsAt 30-days, mortality was 1.3% following SinCABG as compared to 2.3% after SeqCABG (p=0.13). The postoperative complications rate did not differ between groups. Early postoperative coronary angiographies were performed in 127 patients (7%), while clinically indicated follow-up coronary angiographies were performed in 372 patients (20%) over a median follow up of 5 years (IQR 1.7-8.9). No differences in early or late patency rates were found between both grafting techniques (p=0.79 and p=0.39, respectively). The median duration of long-term clinical follow-up was 8.4 years (IQR 5.6-11.4). Long-term survival rates at 1, 5, 10 and 15 years in SinCABG versus SeqCABG were 95% versus 94%, 83% versus 82%, 63% versus 62%, and 47% versus 41%, respectively (p=0.22). ConclusionsShort and long-term mortality as well as early and late graft patency rates did not differ in patients undergoing SinCABG as compared to patients undergoing SeqCABG.

Computational fluid dynamics analysis of bypass surgery for a giant internal carotid artery aneurysm

Computational fluid dynamics analysis of bypass surgery for a giant internal carotid artery aneurysm

Percutaneous Coronary Intervention Versus Robotic Coronary Bypass for Left Anterior Descending Artery Chronic Total Occlusion

BackgroundBoth percutaneous coronary interventions (PCIs) and robotic-assisted coronary artery bypass (CAB) offer viable options for left anterior descending (LAD) chronic total occlusion (CTO) revascularization. Our study aims to compare long-term clinical outcomes associated with these 2 strategies. MethodsIn this retrospective study, we analyzed data from 273 patients diagnosed with LAD CTO who underwent either PCI (n = 129) or CAB (n = 144) at a single institution. Long-term follow-up was available for 96 PCI and 125 CAB patients. We employed Kaplan-Meier curves and the log-rank test to conduct cumulative survival analyses free of major adverse cardiovascular events (MACE), cumulative survival, survival free of myocardial infarction, and repeat revascularization. ResultsIn the study cohort, patients who underwent PCI exhibited a higher prevalence of comorbidities including diabetes (48.9% vs 24.6%; P < .001), lower ejection fraction (44 ± 14 vs 52 ± 10; P < .001), prior heart failure (36.6% vs 22.2%; P = .02), and prior bypass surgery (16% vs 0, P < .001). PCI to non-LAD vessels was performed as part of initial complete revascularization in 40.3% of PCI and 40.6% of CAB patients. Upon a median 3.4 years of follow-up, CAB patients had significantly higher rates of survival free of MACE compared to PCI patients (unadjusted hazard ratio, 2.39; 95% CI, 1.13-5.03). Although PCI patients had similar unadjusted mortality, they experienced higher myocardial infarction and repeat revascularizations compared to CAB. However, the risk of repeat revascularization was attenuated after adjusting for prior bypass, diabetes, and ejection fraction. ConclusionsAmong patients with LAD CTO, those undergoing robotic-assisted CAB had a higher 5-year overall survival free of MACE compared to those who underwent PCI. This discrepancy in outcomes can be attributed in part to the greater burden of comorbidities among PCI patients.

TCT-705 Comparative Outcomes of Endovascular Intervention Versus Bypass Surgery for Peripheral Artery Disease in Patients With Atrial Fibrillation: A Retrospective Analysis of the National Inpatient Sample

TCT-705 Comparative Outcomes of Endovascular Intervention Versus Bypass Surgery for Peripheral Artery Disease in Patients With Atrial Fibrillation: A Retrospective Analysis of the National Inpatient Sample

International Validation of the Vascular Registry of Switzerland, Swissvasc: A VASCUNET Report

Data validity and completeness is essential for registry data, and a meaningful interpretation of differences between countries can only be made if the data are robust within each of the countries. Therefore, the VASCUNET collaboration has performed validation of several vascular registries and has so far published the validation results of national vascular registries of Sweden, Denmark, and Malta. The findings of the validation of the Swissvasc Registry, the vascular registry of Switzerland, are presented here. Five of 34 hospitals participating in Swissvasc were visited by two international validators. Independent evaluation of the procedures of carotid endarterectomy, infrarenal abdominal aortic aneurysm (AAA) repair, and bypass surgery for lower extremity arterial disease (LEAD) was performed. Local administrative data and Swissvasc Registry data were compared for external validation, as well as registry data of 15 randomly picked cases within each group with data from individual patient records for internal validation. Hospital administrative data identified 265 carotid, 399 AAA, and 399 LEAD procedures, whereas Swissvasc identified 265 carotid, 398 AAA, and 395 LEAD procedures. Four LEAD procedures were found in hospital administrative data but not in Swissvasc. External validity was 100% for carotids, 99.8% for AAA, and 99% for LEAD. In internal validation, 5.2% of the variable data were missing in Swissvasc, and 2.4% were different from data in patient records, resulting in external validity of 92.8% for carotids, 94.4% for AAA, and 90.1% for LEAD. The VASCUNET template was used for international validation of registry data, and demonstrated that Swissvasc is a reliable system of quality data collection for the participating vascular centres, with excellent external validity and good internal validity. Quality in the Swissvasc registry data was clearly superior to local administrative data.

Midterm Morphological Change of Kommerell's Diverticulum after Hybrid Thoracic Endovascular Aortic Repair

Kommerell's diverticulum (KD) is associated with a high incidence of right-sided aortic arch (RAA). Hybrid thoracic endovascular aortic repair (TEVAR) is an effective and less invasive alternative to open repair. However, the long-term results regarding KD diameter regression or symptom improvement remain inadequately described. Nine patients underwent TEVAR for KD associated with RAA between January 2016 and September 2023 at our university hospital and affiliated institutions. A hybrid procedure was performed to exclude KD by blocking the proximal blood flow with TEVAR and distal blood flow with embolization of the aberrant subclavian artery. Simultaneously, extra-anatomical bypass surgery was performed to revascularize the covered supra-arch vessels. The patients' mean age was 65.2 years, and six patients were men. Two patients presented with dysphagia, whereas the rest were asymptomatic. The mean diameter and distance to the opposite aortic wall of KD were 32.1 mm and 56.2 mm, respectively. For revascularization of the covered supra-arch vessels, six and two patients underwent total debranching with sternotomy and extra-thoracic bypass (bilateral common carotid artery-axial artery bypass), respectively. The 30-day and in-hospital mortality rates were 0%, with no instances of cerebral infarction or spinal cord ischemia. The mean follow-up period was 3.2 years. The survival and avoidance rates of aortic events were 100% at 1 and 3 years. Follow-up computed tomography scans showed no endoleaks; however, one (11.1%) type 2 endoleak from the aberrant left subclavian artery occurred 1 week postoperatively, necessitating additional coiling. Seven patients were followed up for more than 1 year, with five experiencing reductions of more than 3 mm in KD diameter, distance to the opposite aortic wall, or both. Although further follow-up and investigations are needed, TEVAR may be a safe and effective surgical treatment for KD associated with RAA.

Effect of cold vapor for sore throat reduction in elderly patients with cardiac surgery: A randomized control trial

Cold vapor has anti-inflammatory properties, and can also relieve endotracheal complications like sore throats. As elderlies are more prone to post-extubation sore throat, this study investigates the effect of cold vapor on post-extubation sore throat in the elderly undergoing coronary artery bypass surgery. A randomized controlled trial was carried out on eighty elderly patients undergoing elective coronary artery bypass surgery at a cardiovascular therapeutic center in Iran. Participants were randomly assigned to each experimental and control group using the block randomization method (n=40 in each group). The experimental group received cold vapor after endotracheal tube extubation and the control group received no treatment. Data were gathered at different time intervals 6, 12, 18, and 24 hours after post-extubation using the verbal rating score. Both descriptive and inferential statistics were used to answer the research questions of this study. The results showed that the number of sore throats was significantly different between the two study groups over the four data collection points (p &lt; 0.05). Although the number of sore throats decreased in the control group, they were 0.51 times more likely to develop sore throats (Exp (B)=0.51). Cold vapor is a safe and easy strategy used by nurses for alleviating post-extubation sore throat in elderly patients after coronary artery bypass surgery. Combined with other therapeutic measures, cold vapor can be more effective and can reduce the chance of developing sore throats in these patients.

Early postoperative outcomes of modified del Nido cardioplegia in coronary artery bypass surgery in patients with low ejection fraction

Background: This study aimed to investigate the intraoperative and early postoperative effects of modified del Nido cardioplegia (DNC) compared to classic blood cardioplegia (BC) in patients with impaired left ventricular ejection fraction (EF) who underwent isolated coronary artery bypass grafting (CABG). Methods: A total of 123 patients (108 males, 15 females; mean age: 62.2±8.5 years; range, 42 to 78 years) with an EF of 35% or lower who underwent on-pump CABG were included in the retrospective study between December 2022 and December 2023. The patients were divided into two groups according to the type of cardioplegia used: Group 1 (n=74) was designated as the BC group, and Group 2 (n=49) was designated as the DNC group. The groups were compared in terms of aortic cross-clamp duration, cardiopulmonary bypass (CPB) duration, need for defibrillation during weaning from CPB, positive inotrope requirement, intra-aortic balloon pump requirement, postoperative troponin-I levels, postoperative atrial fibrillation occurence, postoperative prolonged ventilation, development of postoperative neurologic complications, need for reintervention due to postoperative bleeding, postoperative transfusion requirement, and EF values at one month after the operation. Results: There was no significant difference between the two groups in the terms of aortic cross-clamp and CPB duration (p=0.955 vs. p=0.816). Additionally, there was no significant difference in the need for intra-aortic balloon pump usage between the two groups (p=0.105). Dopamine and dobutamine usage were significantly lower in Group 2 (p=0.04 and p=0.05, respectively). The intraoperative requirement for defibrillation was significantly lower in Group 2 (p=0.01). In addition, troponin levels at 12 h postoperatively were significantly lower in Group 2 (p=0.03). The incidence of postoperative atrial fibrillation was significantly lower in Group 2 (p=0.02). Moreover, there was no significant difference in EF values at one month after the operation (p=0.08). Conclusion: In patients who underwent CABG with reduced EF, modified DNC provided myocardial protection comparable to classic BC. Additionally, the need for intraoperative defibrillation and postoperative inotropic agents, as well as the incidence of postoperative atrial fibrillation, were lower in patients operated with DNC.

Limb Salvage and Treatment of Posttraumatic Lymphedema in a Mangled Lower Extremity

Summary: Post traumatic lymphedema (PTL) is a known complication of extremity trauma that is detrimental to limb form and function, healing, and quality of life. In cases of complex lower extremity trauma with vascular and extensive soft tissue injury, the risk of PTL is increased. However, many trauma patients are lost to follow-up, making the risk and potential management of these patients’ lymphedema difficult to characterize. The purpose of this report is to describe the successful surgical management of PTL secondary to significant lower extremity trauma requiring complex limb salvage reconstruction. A 43-year-old woman involved in a motorcycle accident presented with a Gustilo IIIB right tibial fracture and single-vessel leg. She underwent successful limb salvage with serial debridement, bony fixation, creation of an arteriovenous loop with a contralateral saphenous vein graft, and a chimeric latissimus dorsi-serratus anterior muscle flap. At the 5-month follow-up, she presented with significant right lower extremity lymphedema. She underwent lymphovenous bypass surgery guided by preoperative indocyanine green lymphography, which resulted in a 62% improvement in functional outcome measures, eliminated her prior need for compression garments and inability to wear regular shoes, and sustained improvement at two years follow-up. This case illustrates a near circumferential traumatic defect reconstructed with a muscle flap and successful delayed lymphatic reconstruction with lymphovenous bypass in the same patient.